Test of CDEs in Primary Care Under Endo Guidance "Better Than Any New Drug," Researcher Says

Mary Caffrey

A study found that certified diabetes educators embedded in a primary practice, while consulting with an endocrinologist, were able to dramatically improve A1C in a short time by overcoming clinical inertia.

Paresh Dandona, MD, PhD, is the Distinguished Professor and Chief of Endocrinology at the State University of New York at Buffalo, and director of the Diabetes and Endocrinology Center of Western New York. He is on the editorial board of Diabetes Care and is the author or co-author on more than 500 papers.

But Dandona noticed that the 2 certified diabetes educators (CDEs) in his clinic had more ability than he did to motivate patients. Of one, Mary Bierbrauer, RN, BSN, CDE, he said, “The way she transmitted my messages to my patients was much more effective.”

Dandona wondered, “Maybe we can reproduce this in the primary care setting.” If highly trained CDEs in a family practice could still consult with an endocrinologist, would the problem of clinical inertia be overcome?

From this observation came a small study, presented Friday at the annual meeting of the American Association of Diabetes Educators (AADE), that Dandona believes should make those in diabetes care take notice:

When he dispatched CDEs to work alongside a primary care physician (PCP), but under his guidance, the educators were able to gain significant improvements in glycated hemoglobin (A1C) in diabetes patients, which Dandona deemed “better than any new drug.”

The results, which have been submitted for publication, are dramatic: the 100 patients managed by the CDEs had a mean A1C reduction of 1.6% after 6 months, while a control group of 45 patients treated only by the PCP saw a reduction of only 0.26%. Patients treated by the CDEs lost more weight as well, with body mass index (BMI) falling by 1.3 in the intervention group, compared with 0.1 for the control group. The CDE-treated group also recorded improvements in blood pressure, low-density lipoprotein (LDL) cholesterol, and triglycerides superior to those in the controls.

There were some differences between the 2 groups. The intervention group was slightly younger (mean age of 58 years vs 61 years), and a much higher share of the group had been diagnosed within the past 5 years (62% vs 42%). But as Dandona explained, that may be the point. Too often, he said, PCPs fail to make timely adjustments to treatment regimens early in the course of the disease, when patients are known to respond better to therapy.

Maintenance of elevated A1C is not enough, he said. In primary care, the expectations are often too low. “You didn’t expect them to change, and they did not change,” he said. By the time patients with advance disease get to his clinic, the window of opportunity has often closed, he said.

This is a critical issue, he said, since shortages of endocrinologists, an aging population and more chronic disease will require most diabetes management to occur in the primary care setting. Diabetes will continue to slowly progress, “unless we wake up the PCP to the devastating effects of diabetes.”

Deploying trained CDEs into primary care can help tackle the “mountain of diabetes,” he said. This is a a group that is highly committed, but they need guidance from specialists.

The data reveal that the CDEs were more aggressive in making therapeutic changes: 52% of the CDE group had modifications to their regimen, compared with 37.7% of the PCP group. Of note, the A1C decline was greater among patients who had a therapy change (mean of 1.9%) compared with those whose therapy was not changed (1.1%).

After the 6-month intervention, when patients returned to management by the PCP alone, the A1C reduction in the intervention group diminished somewhat, to a decline of 1.2% at 12 months. This was still greater than the decline in the control group, which was 0.7% at 12 months. Notably, the average A1C for the intervention group was below 7% at 6 months, but crept back up to 7.8% after patients stopped seeing the CDE. In the control group, the average A1C was 8% at 6 months and 7.9% at 12 months.

Of note, benefits in blood pressure, weight loss, triglycerides, and LDL cholesterol were largely maintained in the CDE group, despite the rise in A1C at 12 months.

Dandona said the results highlight the problem of clinical inertia, which affect his ability to change patient behavior when patients progress and are referred to him.

“There are a lot of patients who need attention, but we are basically siting there doing nothing,” he said. When these patients get to the endocrinologist, “they are already reticent in changing their habits, because for years they’ve been told they are perfectly OK.”

The results also show how the standards of care could be revolutionized by “letting loose” CDEs to take a more active role in primary care. “CDEs working with endocrinologists can change outcomes in a really remarkable fashion, such that the whole face of diabetes can be changed,” he said.

AACE's annual meeting continues through Monday in San Diego, California.